One-Hour Power Break webinar - Rather wreck my … › sites › ...One-Hour Power Break webinar - Rather wreck my gums than my lungs: Smokeless tobacco and California rural adolescent

One-Hour Power Break webinar - Rather wreck my gums than my lungs: Smokeless tobacco and California rural adolescent males

Benjamin Chaffee, DDS, MPH, PhD

8/30/17

Moderator

Catherine Saucedo

Deputy Director Smoking Cessation Leadership Center University of California, San Francisco [email protected]

8/30/17 Smoking Cessation Leadership Center

Disclosures This UCSF CME activity was planned and developed to uphold academic standards to ensure balance, independence, objectivity, and scientific rigor; adhere to requirements to protect health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA); and include a mechanism to inform learners when unapproved or unlabeled uses of therapeutic products or agents are discussed or referenced. The following faculty speakers, moderators, and planning committee members have disclosed they have no financial interest/arrangement or affiliation with any commercial companies who have provided products or services relating to their presentation(s) or commercial support for this continuing medical education activity: Benjamin Chaffee, DDS, MPH, PhD, Christine Cheng, Brian Clark, Jennifer Matekuare, Roxana Said, MPH, Catherine Saucedo, and Steven A. Schroeder, MD


Thank you to our funders


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CME/CEU Statement Accreditation:

The University of California, San Francisco (UCSF) School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

UCSF designates this live activity for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the webinar activity.

Advance Practice Registered Nurses and Registered Nurses: For the purpose of recertification, the American Nurses Credentialing Center accepts AMA PRA Category 1 CreditTM issued by organizations accredited by the ACCME.

Physician Assistants: The National Commission on Certification of Physician Assistants (NCCPA) states that the AMA PRA Category 1 CreditTM are acceptable for continuing medical education requirements for recertification.

California Pharmacists: The California Board of Pharmacy accepts as continuing professional education those courses that meet the standard of relevance to pharmacy practice and have been approved for AMA PRA category 1 creditTM. If you are a pharmacist in another state, you should check with your state board for approval of this credit.

Respiratory Therapists: This program has been approved for a maximum of 1.0 contact hour Continuing Respiratory Care Education (CRCE) credit by the American Association for Respiratory Care, 9425 N. MacArthur Blvd. Suite 100 Irving TX 75063, Course # 149246000.


Presenter

Benjamin Chaffee, DDS, MPH, PhD Assistant Professor Division of Oral Epidemiology and Dental Public Health University of California San Francisco


Rather Wreck My Gums Than My Lungs: Smokeless Tobacco and California Rural Adolescent Males

Benjamin Chaffee, DDS MPH PhD UCSF School of Dentistry Division of Oral Epidemiology & Dental Public Health UCSF Center for Tobacco Control Research & Education

9

Acknowledgments

UCSF TCORS Project 3 UCSF TCORS & CTCRE

Funding:

NIH NCI/FDA P50CA180890 NIH NCATS KL2TR001870

Content solely the responsibility of authors and does not necessarily represent the official views of funding organizations

Neal Benowitz Victoria Campbell Taranvir Cheema Jing Cheng Elizabeth Couch Ellen Darius Gwen Essex Stuart Gansky Joanna Hill Catherine Kavanagh Janna Murray Archnaa Rajasekaran Janelle Urata Margaret Walsh

Janine Cataldo Stanton Glantz Bonnie Halpern-Felsher Jonathan Leff Pamela Ling Maria Roditis Karen Williams ...and entire TCORS team

10

Dr. Margaret (Peggy) Walsh

Dr. Walsh was a visionary leader in education and research

11

Smokeless Tobacco: Adverse Health Effects

Oral conditions Oral and pharyngeal cancer Mucosal lesions Gingival keratosis Periodontal disease Tooth discoloration Enamel erosion Gingival recession Dental caries

Other conditions Pancreatic cancer Stomach cancer Hypertension Cardiovascular Disease Smoking initiation among young users

12

Conventional Smokeless Tobacco (ST)

Oral moist snuff (“dip”) Finely ground tobacco Typically placed between buccal mucosa and gingiva and held in place

Chewing tobacco (“chew”) Coarsely shredded tobacco Sold in bricks, twists, or loose-leaf Placed in mouth and chewed

13

The Changing (Smokeless) Tobacco Landscape

14


Acquisition of ST manufacturers by major cigarette companies

15


ST Industry Marketing Expenditures Spike After Acquisition by Cigarette Makers

1985 1995 1990 2000 2010 2005

$100M

$400M

$300M

$200M

$500M

$600M

$700M

2015

Source: Federal Trade Commission

2006 - 2010: Altria & Reynolds Purchase Smokeless Companies

16


Major growth in marketing expenditures on magazine ads & price discounts

Sources: Federal Trade Commission and http://www.tobaccofreekids.org/research/factsheets/pdf/0003.pdf

trinketsandtrash.org

17


Greater diversity in ST product types and varieties

Options in price, flavor, cut & nicotine content may appeal to youth

18


Rising popularity and normalization of other non-cigarette products (e.g. e-cigarettes, marijuana)

19

Adolescent Tobacco Use, United States (males, grade 9 -12)

Past Month Use, %

1999 ’01 ’03 ’05 ’07 ’09 ’11 ’13

Cigarettes

Source: Youth Risk Behavior Survey

2015

20

Source: Youth Risk Behavior Survey

Smokeless Tobacco

Past Month Use, %

1999 ’01 ’03 ’05 ’07 ’09 ’11 ’13

Cigarettes

2015

Adolescent Tobacco Use, United States (males, grade 9 -12)

21

Populations at risk of smokeless tobacco use

Male Young adult Non-Hispanic White Lower-income & education Rural


22

Populations at risk of smokeless tobacco use

Male Young adult Non-Hispanic White Lower-income & education Rural


23

(election map)

Map credit: Mark Newman http://www-personal.umich.edu/~mejn/election/2016/

United States 2016 Presidential Election: Voting by County

24

Why Study Smokeless Tobacco Use in California?

25

1.9 million Californians live in rural areas

26

California Counties: Population Density

27

California Counties: Population Density

California Counties: % ST Ever-Use

11th Grade

Data Source: California Healthy Kids Survey

28

Baseball teams at 36 rural California high schools (Recruited: 2014-2016)

Assess: • ST use patterns • Risk perceptions • Decision-making • Biological markers of nicotine

and carcinogen exposure

Smokeless Tobacco Use Among Rural High School Baseball Players in California

29

Smokeless Tobacco and Sports

Elevated ST use in baseball, hockey, football, rodeo, wrestling, auto racing


Getty Images

Smokeless Tobacco and Sports

Elevated ST use in baseball, hockey, football, rodeo, wrestling, auto racing

Exceedingly high in organized baseball Modeled use by admired athletes during widely broadcast games Tobacco marketing infiltrates baseball culture and tradition

32

57%

37% 36% 31% 31%

22%

12%

Ever tried tobacco products (at least one time)

Any Tobacco

Dip/Chew E- Cigarettes

Cigars Hookah Cigarettes Snus

Rural California High School Males (N = 594)

33

Current (past month) tobacco use

Dip/Chew E-Cigarettes Cigars Hookah Cigarettes Snus

18%

9% 9% 8%

6%

4%


34

Past month tobacco use & daily use

Dip/Chew E-Cigarettes Cigars Hookah Cigarettes Snus

Daily use 18%

9% 9% 8%

6%

4%


No Combustible Use Combustible Use

14%

51%

Correlates of Past Month Smokeless Tobacco Use

Other Non-Hispanic White

13%

22%

< College Degree College Degree

16% 17%

9th 11th

9%

21%

10th 12th

13%

33% Race/Ethnicity

Parental Education

Grade in School

Other Tobacco Use

36

Correlates of Past Month Smokeless Tobacco Use

None ≥1 Family Member

13%

27%

Family Member ST Use Perceived Number of Teammates Who Use ST

None Few

4%

14%

Some Half Most

37% 36%

30%

Smokeless Tobacco in Major League Baseball

Officially banned in minor leagues (1993)

Cannot be carried in uniform (2012)

Some cities ban tobacco in ballparks (2015-2016)

New major leaguers cannot use in games (2017)


Officially banned in minor leagues (1993)

Cannot be carried in uniform (2012)

Some cities ban tobacco in ballparks (2015-2016)

New major leaguers cannot use in games (2017)


Momentum encouraging, but... Rules are patchwork and practically unenforceable

40 Ezra Shaw, Getty Images

2015 National League Most Valuable Player

41 Ezra Shaw, Getty Images

2015 National League Most Valuable Player

42

Do you think your favorite Major League Baseball player uses smokeless tobacco (dip or chew)?

43


Definitely Yes

Probably Yes

Definitely No

Probably No

44


Definitely Yes

Probably Yes

Definitely No

Probably No

Ever-tried ST: 25% Current ST: 8%

45


Definitely Yes

Probably Yes

Definitely No

Probably No



46

Susceptibility to ST initiation High school baseball players (ST never-users)

Would Try ST if Best Friend Offered

10%

40%

30%

20%

Probably Yes

Definitely Yes

Probably Not

Definitely Not

Does Your Favorite MLB Player Use ST?

50%

Think You Will Use ST a Year from Now

47

Susceptibility to ST initiation High school baseball players (ST never-users)

Would Try ST if Best Friend Offered

10%

40%

30%

20%

Probably Yes

Definitely Yes

Probably Not

Definitely Not

Does Your Favorite MLB Player Use ST?

50%

Think You Will Use ST a Year from Now

48

Qualitative Study of Smokeless Tobacco Decision-Making

49

Qualitative Study of Smokeless Tobacco Decision-Making

Interviews with high school males (ST users and non-users)

Perceived acceptability, health risks, and social context of ST use

trinketsandtrash.org 50

• ST related to rural or country way of life

• Part of community tradition and culture

"Country" Culture

trinketsandtrash.org 51

• ST related to rural or country way of life

• Part of community tradition and culture

“The group I hang out with, like boots, blue jeans…they're like cowboys, like country kids – [ST] is really accepted. It's just like a thing that

happens. No one even takes a second look at it.” (current-user, age 17)

"Country" Culture

52

Never-users: Strong anti-tobacco expectations from parents motivated avoidance

Family Influences

53

ST Users: Modeling by family members reinforced acceptance


Family Influences

54

ST Users: Modeling by family members reinforced acceptance

“[My parents] think [ST is] gross, but they also think that I'm old enough to make my own decisions.”

(current-user, age 17)


ST Users: Parents superficially disapproving yet permissive or reluctantly accepting

Family Influences

55 trinketsandtrash.org

ST use a way to express newly earned independence

Chewing in light of health risks signaled reaching an age that required less protection from potential dangers

Maturity and Independent Choice

56 trinketsandtrash.org

ST use a way to express newly earned independence

“I'm doing it at my own risk, and it's something I decided to do.”


Chewing in light of health risks signaled reaching an age that required less protection from potential dangers

Maturity and Independent Choice

57

High awareness of oral health risks: mouth cancer, tooth loss, and gum disease

Perceived Health Risks

58

High awareness of oral health risks: mouth cancer, tooth loss, and gum disease

“Your teeth rot away. Makes your breath smell bad.

Makes your teeth turn different colors. Gums, you lose your

gums. Teeth start to fall out.” (experimenter, age 17)

Perceived Health Risks

59

Many users framed ST as an alternative to cigarettes with greatly reduced risk of systemic disease

“Cigarettes, it goes into your body and through your lungs and into everything like that... chewing

tobacco just stays in my mouth.”


“Cigarettes, you have lung damage. Makes your skin all wrinkly. Chew, just your gums and teeth.

Your lungs are fine still.”

Risks Relative to Cigarettes

60

Many users viewed health risks as distant and avoidable

“I haven't had any health problems with [ST] since I have been chewing… I know that if I did

have a health problem, that would probably motivate me to quit.”


Exceptionalism and Avoidable Risk

Risk mitigation strategies: Stay below a threshold of intensity or duration, practice good oral hygiene, not swallow tobacco juices

Smokeless Tobacco and Carcinogens

Tobacco-Specific Nitrosamines (TSNAs):

NNN - oral cancer

NNK - lung and pancreatic cancer



NNN - oral cancer


Swedish snus is a pasteurized, low-nitrosamine moist snuff smokeless tobacco Standards set the maximum allowable level of TSNAs



NNN - oral cancer


Smokeless tobacco products sold in the United States, including snus products, contain much higher TSNA levels Stepanov, et al. (2014) Nicotine Tob Res



NNN - oral cancer


Similar (or higher) levels of NNAL (urinary marker of NNK) in adult smokeless users vs. cigarette smokers Hecht, et al. (2007) Cancer Epidemiol Biomakers

Adult Smokers

Adult ST User

65

FDA estimates: 12,700 cases of oral cancer prevented 2,200 oral cancer deaths prevented in 20 years after implementation

66

FDA estimates: 12,700 cases of oral cancer prevented 2,200 oral cancer deaths prevented in 20 years after implementation

67

Quantifying Tobacco Risk Perceptions

creative commons image

68

In your opinion, how harmful is using dip or chew to general health?


69



Use this scale from 0 to 100

to demonstrate 100 = extremely harmful

0 = not at all harmful

70






71






72






73

Cigarettes E-Cigarettes Dip/Chew Cigars Hookah

standardized for age, race/ethnicity, parental education, and intra-school clustering

90

74 74

61 57

Perceived Harm Differs by Tobacco Product

100 = extremely harmful


74



Never

Tried/Former

Current

Product Use:

Never

Tried/Former

Current

Product Use (ST):

Perceived Harm Differs by Tobacco Product & Use Status

75



Never

Tried/Former

Current

Product Use:

Never

Tried/Former

Current

Product Use (ST):


76



Never

Tried/Former

Current

Product Use:

Never

Tried/Former

Current

Product Use (ST):


77



Never

Tried/Former

Current

Product Use:

Never

Tried/Former

Current

Product Use (ST):


78

Smokeless Tobacco Use

Cigarettes

E-Cigarettes

Perceived ST Harm Declines with Use Frequency

Never Tried/Former 1-9 days/mo. >9 days/mo. Everyday

Smokeless Tobacco

79


Cigarettes

E-Cigarettes



Smokeless Tobacco

80


Cigarettes

E-Cigarettes



Smokeless Tobacco

81

Quantifying Specific Tobacco Risk Perceptions

Imagine you used dip/chew. How likely will happen to you?

82


Use this scale from 0% to 100% to demonstrate

Imagine you used dip/chew. How likely will happen to you?

Get into Trouble

Brown Teeth

Mouth Cancer

83


mouth cancer 78

59

ST never-user

68

40

How likely will happen to you?

84


mouth cancer 78

59

ST never-user

ST ever-user

68

40


How do users and non-users perceive each individual risk?

85


mouth cancer 78

59

ST never-user

ST ever-user

68

40



Are different types of risks perceived in the same way?

86


mouth cancer 78

59

ST never-user

ST ever-user

68

40



Are different types of risks perceived in the same way?

How are different types of risks perceived across tobacco products?

87

Smokeless Tobacco Risk Perceptions: Two Classes

“UNCERTAIN RISKS” “BELIEVABLE RISKS”

Mouth cancer Upset family Bad breath

Heart attack Lung cancer Harm someone nearby


88


“UNCERTAIN RISKS” “BELIEVABLE RISKS”




“UNCERTAIN RISKS” “BELIEVABLE RISKS” 89


ST never-user

ST ever-user How likely will happen to you?





ST never-user

ST ever-user How likely will happen to you?








Ciga

rett

es

Smok

eles

s

Ciga

rett

es

Smok

eles

s

92

Available nicotine & carcinogen content

Form, brand, flavors, price

Positioning of specific products to appeal to novice users

Variation in Smokeless Tobacco Products

93

Flavored ST associated with appealing non-tobacco products: chewing gum, breath mints, fruit, candy, and alcohol

Flavor Associations

trinketsandtrash.org trinketsandtrash.org

94

Flavor Associations

Others had negative perceptions of ST flavors, viewing them as unnatural in comparison to “regular” or “straight” ST


95

Flavor Associations

Others had negative perceptions of ST flavors, viewing them as unnatural in comparison to “regular” or “straight” ST


“Flavored [ST]... makes me feel like it's not real….The stuff that I used the most when I was on it a lot was straight, because in

my mind it was just straight tobacco. It didn't have all this

other stuff in it.” (former-user, age 16)

96

Users sampled brands, flavors out of curiosity or to “switch things up” Special or seasonal offers generated buzz and created urgency to purchase. Some followed ST websites to track new products

Product Switching & Special Offers


97

Users perceived higher “strength” and nicotine content based on brand, type, or flavor

Perceived Product Qualities

98

Users perceived higher “strength” and nicotine content based on brand, type, or flavor

“Copenhagen Wintergreen will give you a real big head rush. It will make you feel different than

Copenhagen Straight.” (former-user, age 16)

Perceived Product Qualities

99

Social pressure was associated with using certain ST products, partly based on perceived product strength (and user toughness)

Perceived Brand Qualities

100

Social pressure was associated with using certain ST products, partly based on perceived product strength (and user toughness)


“They say if you chew Skoal, you're a little girl.” (current-user, age 17)

101

Many users also expressed loyalty when discussing their usual brand

“I think Copenhagen just doesn't need to advertise really. They're just like Marlboro is for cigarettes... Like Nike is for shoes. They're just

like the top of the top.” (current-user, age 17)


102

103

Smokeless tobacco is a sizeable, persistent public health problem; even in California

Implications Don’t overlook rural communities in policy & research


Aggressive, highly effective industry marketing targets young rural males

Implications Don’t overlook rural communities in policy & research

Forceful public health action needed as industry seeks profits beyond smoking



Implications

Perceived community norms and use by others puts youth at risk

Don’t overlook rural communities in policy & research


Go beyond half-measures: full ban with enforcement in professional baseball


Awareness of oral health risks, but these risks dismissed & related to smoked tobacco


Implications





“Wrecks your gums” cannot be only message: emphasize addiction, chemicals

NNN limit Eliminate flavors Restrict ads in youth-oriented magazines Sever connection with sports




Relative harm beliefs associated with youth ST use To achieve harm reduction: make a less harmful product with less youth appeal

Implications









Relative harm beliefs associated with youth ST use To achieve harm reduction: make a less harmful product with less youth appeal

Implications


Today, nearly 1,000 males below age-18 will use ST for the first time





NNN limit Eliminate flavors Restrict ads in youth-oriented magazines Sever connection with sports

110

Q&A

• Submit questions via the chat box


Contact us for technical assistance

• You will receive the webinar recording, presentation slides, information on certificates of attendance, and other resources, in our follow-up email. All of this information will be posted to our website.

• CME/CEUs of up to 1.0 credit is available to all attendees of this live session. Instructions will be emailed after the webinar.

• Visit us online at smokingcessationleadership.ucsf.edu

• Call us toll-free at 877-509-3786

• Please complete the post-webinar survey


CME/CEU Statement Accreditation:

The University of California, San Francisco (UCSF) School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

UCSF designates this live activity for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the webinar activity.

Advance Practice Registered Nurses and Registered Nurses: For the purpose of recertification, the American Nurses Credentialing Center accepts AMA PRA Category 1 CreditTM issued by organizations accredited by the ACCME.

Physician Assistants: The National Commission on Certification of Physician Assistants (NCCPA) states that the AMA PRA Category 1 CreditTM are acceptable for continuing medical education requirements for recertification.

California Pharmacists: The California Board of Pharmacy accepts as continuing professional education those courses that meet the standard of relevance to pharmacy practice and have been approved for AMA PRA category 1 creditTM. If you are a pharmacist in another state, you should check with your state board for approval of this credit.

Respiratory Therapists: This program has been approved for a maximum of 1.0 contact hour Continuing Respiratory Care Education (CRCE) credit by the American Association for Respiratory Care, 9425 N. MacArthur Blvd. Suite 100 Irving TX 75063, Course # 149246000.


American Association for Respiratory Care (AARC) • Free Continuing Respiratory Care Education credit (CRCEs) are

available to Respiratory Therapists who attend this live webinar

• Instructions on how to claim credit will be included in our post-webinar email


Save the Date

SCLC’s next One-Hour Power Break webinar : “The Power of Partnerships: Behavioral health and public health working together to combat smoking in Kentucky”

with the National Behavioral Health Network for Tobacco & Cancer Control and the American Lung Association and the State of Kentucky

Tuesday, September 19, 2017 at 1pm EDT

Registration is open now!


Contact us for technical assistance

• Visit us online at smokingcessationleadership.ucsf.edu

• Call us toll-free at 877-509-3786

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One-Hour Power Break webinar - Rather wreck my … › sites › ...One-Hour Power Break webinar - Rather wreck my gums than my lungs: Smokeless tobacco and California rural adolescent